ORIGINAL RESEARCH published: 17 November 2020 doi: 10.3389/fpsyt.2020.591142

Psychological Effects of Social Isolation Due to Quarantine in Chile: An Exploratory Study

Paula Dagnino 1,2,3*, Verónica Anguita 4,5, Katherine Escobar 1,2 and Sofía Cifuentes 1,2

1 Faculty of Psychology, Universidad Alberto Hurtado, Santiago, Chile, 2 Center for the Research on Psychotherapy—CIPSI, Santiago, Chile, 3 Millennium Institute for Research on Depression and Personality—MIDAP, Santiago, Chile, 4 Ethics Committee of Research With Human Beings, Universidad Alberto Hurtado, Santiago, Chile, 5 Bioethics Department, Faculty of Medicine, Universidad de Chile, Santiago, Chile

As we all know, COVID-19 has impacted the entire world. Quarantine disrupts people’s lives, with high levels of stress and negative psychological impacts. Studies carried out mostly in the Far East, Europe, or the United States have started to provide evidence on survivors, frontline healthcare workers, and parents. The present study is the first survey to be carried out in Latin America (in Santiago, the capital of Chile). It aims to (a) explore the perceived psychological impact and future concerns; (b) evaluate vulnerability factors; (c) describe the perceived psychological impacts on participants whose psychological help and actual online psychotherapy was interrupted; and (d) explore the future need for psychological help. Procedure: An online survey was carried Edited by: Dinesh Kumar Bhugra, out (the first 2 weeks of lockdown in Santiago), which included sociodemographic data, Institute of Psychiatry, Psychology and perceived psychological impact, future concerns, and questions about psychological Neuroscience, United Kingdom support. Participants: A total of 3,919 subjects answered, mostly women (80%). Results: Reviewed by: The main perceived psychological impacts were concern (67%) and anxiety (60%). Future Luigi Janiri, Catholic University of the Sacred concerns were: general health (55.3%), employment (53.1%), and finances (49.8%). Heart, Italy Younger participants had a greater perceived psychological impact (p’s < 0.01) and M. Mahbub Hossain, Texas A&M University, United States concerns about employment, finances, mental health, stigma, and general health (p’s Maria Casagrande, < 0.001). Women reported more perceived psychological impact than men (p’s < 0.05). Sapienza University of Rome, Italy Men reported mainly boredom (χ 2 = 11.82, gl = 1, p < 0.001). Dependent employees *Correspondence: experienced more boredom, anxiety, distress, sleep problems, an inability to relax, and Paula Dagnino [email protected] a lack of concentration than the self-employed (p’s < 0.05). While the latter reported future concerns about employment and finances (p’s < 0.001), dependent employees Specialty section: reported them on their general and mental health (p’s < 0.001). Regarding psychological This article was submitted to Public Mental Health, support, 22% of participants were receiving it before lockdown. They showed more a section of the journal perceived psychological impact than those who were not (p’s < 0.01), and 7% of Frontiers in Psychiatry them had online psychotherapy, reporting excellent (32.1%) or odd but working (65.2%) Received: 03 August 2020 results. Finally, of the total sample, almost half of the participants (43.8%) felt they would Accepted: 19 October 2020 Published: 17 November 2020 need emotional support after this pandemic, and these are the ones that also showed Citation: higher perceived psychological impact (p’s < 0.001). This study confirms the presence Dagnino P, Anguita V, Escobar K and of perceived negative emotional impact and concerns about the future. Also, there are Cifuentes S (2020) Psychological Effects of Social Isolation Due to vulnerable groups, such as women, younger people, the self-employed, and people with Quarantine in Chile: An Exploratory psychological processes that were interrupted. Study. Front. Psychiatry 11:591142. doi: 10.3389/fpsyt.2020.591142 Keywords: psychological impact, COVID-19, psychological support, tele-psychotherapy, vulnerability factors

Frontiers in Psychiatry | www.frontiersin.org 1 November 2020 | Volume 11 | Article 591142 Dagnino et al. COVID-19 Psychological Effects in Chile

INTRODUCTION those who stopped working reported worse mental health and more distress. Because of these long-lasting effects, it is extremely There have been several pandemics in human history (e.g., relevant to enquire about the actual psychological impact and Spanish Flu, 1918–1919; Asian Flu, 1957–1958; A1NH1 2009– future concerns during this particular pandemic quarantine in 2010). The current pandemic, COVID-19, has impacted the other regions, such as South America. entire world, starting in China in December 2019. At the time of From all of the studies, it is evident that pandemics such as this writing the manuscript, COVID-19 was affecting 213 countries one, and its concomitant lockdowns, have a massive impact on and territories around the world, with almost 16,575,090 cases people, especially on their mental health, which includes different and 654,623 deaths (1). In Chile, the first case of COVID was a feelings about it and future concerns. Identifying these is very 33-year-old man who had to be hospitalized on 3 March. The first important in terms of taking measures to prevent or treat the death took place on 21 March. psychological impact. Few studies have evaluated these issues This study was carried out in Chile between 23 March and 15 among the general population (25, 31), mainly targeting specific April 2020. At the end of the survey, 95 people had died out of people such as health professionals [e.g., (4, 32–34)], COVID-19 8,273 confirmed cases (2). Artificial respirators and ICUs were at survivors (33), or specific age groups (35). ≤20% occupancy (3). From COVID-19 studies, particular vulnerability factors have In the history of pandemics, one of the viruses with a been identified. As such, they increase the presence of a negative worldwide impact was H1N1, which had an infection rate emotional impact due to quarantine. Some of these are gender, of ∼1.6 infected by one subject with the virus, and its educational level, and age [e.g., (28, 36)]. Findings on gender symptomatology was quickly evident (4, 5). COVID-19 has a suggest that women are more vulnerable to stress than their higher level of contagion, estimated at 4.08 (5), and it also male counterparts (4, 37), increasing the possibility of developing presents characteristics that are mutating, such as the symptoms post-traumatic disorders afterwards (19, 31). On the other hand, and presence of the virus, even in asymptomatic conditions (4– people with a higher level of education tend to have more distress, 6). These cause high levels of anxiety and fear about the future probably because of a high level of self-awareness about their (7, 8). Countries around the world have established more or less health (19, 37). Concerning age, individuals between 18 and strict quarantine measures. It is believed that confinement, such 30 years of age, or above 60, presented the highest levels of as social isolation, helps to prevent the spread of the virus (9). emotional distress (19). Younger people, such as college students, Quarantine or social isolation disrupts people’s jobs and lives showed that they were experiencing anxiety during COVID-19 immensely, and hence it may have important implications for (4, 35). Other studies found that one of the vulnerability factors their health and well-being (7, 8). These necessary measures lead for screening anxiety or depression was a younger age (31, 36). the general population to a high level of stress and psychological Some studies in Italy have related the impact of quarantine to problems, producing uncertainty, fear of contagion, and illness personality traits such as negative affect and attachment, finding in themselves and their loved ones, and a fear of financial loss(7, that detachment and negative affect were related to depression, 10, 11). Separation from loved ones, loss of freedom, losing direct anxiety, and stress (25). social contact, employment, recreation, privileges, boredom(12), Besides vulnerability factors, concerns about the present and and uncertainty over the disease’s status, on occasion, create future are among the main issues that lead to high stress during dramatic effects that are among the significant stressors that will lockdown. As is expected for infectious disease, the main concern undoubtedly contribute to widespread emotional distress (13). is about becoming sick or that a family member will (7). However, Indeed, the well-being implications of quarantine were there have also been high economic consequences related to evident in previous outbreaks such as SARS or MERS. After other pandemic conditions (38). In the SARS outbreak in Canada quarantine, hospital staff showed more acute stress disorders(13) and the United States, concern about financial loss meant that and post-traumatic symptoms, even 3 years later (14). Among the people did not comply with quarantine or evacuation (37, 39– general population, anger and anxiety were predominant, mainly 41). Also, months after SARS struck in China, the fear of because of economic concerns several months later (13), with an income reduction was among the highest vulnerability factors increase in the number of suicides (15, 16). for psychological disorders (39). Specifically, with the COVID- The studies that have been done so far on the COVID- 19 pandemic, college students have been worried about the 19 pandemic, and especially on the effects of quarantine, have economic influences of the epidemic, which are related to the shown a high negative psychological impact. These studies were high levels of anxiety (24, 35). Therefore, not only are the conducted mostly in the Far East, Europe, or the United States, concerns about health issues relevant, but economic or financial and they have started to provide showing adverse emotional matters will also be highly prevalent. effects such as increased stress, depression, anxiety, sleeping However, there is another part of the population that has gone difficulties, post-traumatic stress, anger, boredom, stigma, unnoticed, namely, those who were having psychological help substance use, and loneliness (17–28). Moreover, some studies before lockdown. Few studies have focused on this type of person, have compared negative emotions before lockdown and during concentrating instead on psychiatric patients or inpatients [e.g., the COVID-19 outbreak. The results have shown that there has (42)], showing that quarantine exacerbates existing mental been an increase in negative emotions during lockdowns, such as health disorders (43–45), or asking about psychological support anxiety and depression (7, 29), and a decrease in life satisfaction or psychotherapy as one of the areas but not relating it to (30). After 1 month of confinement, Zhang et al. (22) found that psychological distress or symptoms (25). Diagnosed before the

Frontiers in Psychiatry | www.frontiersin.org 2 November 2020 | Volume 11 | Article 591142 Dagnino et al. COVID-19 Psychological Effects in Chile pandemic, mental health symptoms are associated with anxious between 47 and 55 years of age, and, finally, 19.37% participants and irritable symptoms 4–6 months after quarantine (46, 47). were between 55 and 89 years of age. For the sample, only However, in the area of mental health, not only must people participants over 18 years of age were considered. Forty-six with severe mental disorders be taken into account, there are percent of the participants reported being employed workers, also people who were having psychological outpatient help before while 26% reported being self-employed. lockdown (48). These people have faced not only the impact of social isolation and quarantine, but also without this support. For Procedure this reason, they need to be evaluated, as they are likely to have a In order to fulfill the objectives, an online survey was carried different or more intense perceived psychological impact. out (disseminated through personal and social networks) from We know that there has been an increase in the development 23 March to 15 April 2020 (23 days). This coincided with the of online psychotherapy (i.e., providing mental healthcare first case of COVID-19 in Chile and the government’s subsequent remotely, using telecommunications such as telephone or video decision to keep the pandemic under control through a lockdown conferencing tools), which has been introduced suddenly and of Santiago. expanded significantly to serve patients at treatment or in This study was reviewed and approved by the Institutional actual need of treatment (49). Many discussions of clinicians on Review Board of the Universidad Diego Portales (N◦006-2020), organizations and some qualitative studies (50) have emerged which conformed to the principles embodied in the Declaration with the intention of evaluating the impact of this new approach of Helsinki. All respondents provided informed consent. on therapists and their settings, and yet, no review has asked patients how they have experienced this change. This is an Measures essential issue, since other pandemics had shown that mental Survey Development health support and follow-up should be provided even 6 months As a result of the need to screen several psychological symptoms after release from isolation for those individuals with or without a that could appear during the COVID-19 pandemic, the survey prior vulnerable mental health status (51). How patients evaluate items were developed with a focus on previous surveys on the the effectiveness of this new approach will be relevant to installing psychological effects of SARS, Ebola and influenza outbreaks, and it as a modality to be performed in the future, in both online actual studies on COVID-19 (see Introduction). Specifically, we psychotherapy and online psychiatry. focused on Brooks et al.’s (52) revision, since it provided very The COVID-19 epidemic has caused a parallel epidemic of thorough evidence on the psychological impact of quarantine. fear, anxiety, and depression worldwide, along with concerns Brooks et al. (52) reviewed 903 studies on the prevalence of about the future. This study is the first to evaluate the perceived psychological symptoms, and they found that the most prevalent psychological impact on a South American country such as Chile. were insomnia, irritability, fear, stress, depression, concern, The objectives are to (a) survey the general public to understand anxiety, and fear. Other input was Taylor’s book (17), with the better their levels of psychological effect and future concerns; (b) most reported psychological impact in almost all pandemics identify relationships between vulnerability factors (age, gender, being anxiety, concern, fear, stress, uncertainty, irritability, and occupation), perceived psychological impact, and future and depression. interests; (c) describe the perceived psychological effects on New dimensions appeared in Zhang et al. (22), which survey participants who had processes interrupted because of this considered working conditions to be a vulnerability factor for pandemic, and evaluate online psychotherapy; and (d) explore psychological distress. Other authors [e.g., (52, 53)] mentioned the future need for psychological help. It is hypothesized that the effect on financial loss of quarantine and therefore economic there will be perceived psychological impacts, such as anxiety and concerns as a stressor. With this input, the authors decided to depression. Also, future concerns will appear mainly related to separate the psychological impact from concern, mainly because overall health and economic issues. Furthermore, vulnerability quarantine was just starting in Chile and the future was therefore factors such as being a woman, younger, and self-employed may a big issue. reveal differences. Finally, it is expected that those who had their On the other hand, as three of the four authors are clinical processes interrupted will be more emotionally affected and that psychologists, the question was quickly raised about how patients virtuality may help them. Finally, it is expected that there will who were having help were managing to cope without it, and be a significant percentage of people who think they will need virtuality was also increasingly being used in Chile at the time, psychological help in the future. so there was a need to understand the subjective experience of patients of this new helping tool. MATERIALS AND METHODS Therefore, the survey consisted of 16 questions, which evaluated several areas: (a) sociodemographic data (gender, age, Participants education, and occupation); (b) the perceived psychological The sample comprised 3,919 participants, living in Santiago (the impact of quarantine; (c) future concerns; and (d) psychological capital of Chile) (80% women). Participants’ age ranges were support (pre-quarantine support, actual support, and future created based on a quantile cutoff criterion, using the 20, 40, support needs). 60, and 80 quantiles. Accordingly, 20.0% of participants ranged Regarding the actual perceived psychological impact, from 18 to 29 years of age, 20.3% were between 30 and 38 years respondents had to select one or more of the following perceived of age, 21.5% were between 39 and 46 years of age, 18.8% were impacts: boredom, distress, anxiety, lack of concentration,

Frontiers in Psychiatry | www.frontiersin.org 3 November 2020 | Volume 11 | Article 591142 Dagnino et al. COVID-19 Psychological Effects in Chile

frustration, inability to relax, restlessness, irritability, fear, loss TABLE 1 | Number and percentage of reports of the current perceived impact of control, loss of freedom, concern, sleep problems, feeling and future concern. trapped, and loneliness. On future concerns, respondents also Does not report Reports had to select one or more of the following concerns: policy, school, economic issues, work, mental health, overall health, f % f % and stigma. Current impact On psychological support, respondents were asked if they Fear 2,648 67.6 1,271 32.4 were receiving psychological help before quarantine [0 = no; 1 Concern 1,288 32.9 2,631 67.1 = yes], and those who answered affirmatively to this question Frustration 2,898 73.9 1,021 26.1 had to answer the next questions as a sub-sample. First, if they Boredom 2,556 65.2 1,363 34.8 had psychological support, 16 questions had to be answered: how Anxiety 1,556 39.7 2,363 60.3 long they had been receiving help when quarantine started (a Distress 2,324 59.3 1,595 40.7 few sessions, more than 6, or more than 12). They were asked Feeling trapped 2,991 76.3 928 23.7 about why they had started psychotherapy, and they could choose more than one alternative from depression, anxiety, psychosis, Lossofcontrol 3,546 90.5 373 9.5 cognitive and learning problems, personality problems, eating Loneliness 3,283 83.8 636 16.2 disorders, physical problems, addictions, trauma abuse, grief, Sleep problems 2,329 59.4 1,590 40.6 self-esteem, interpersonal relations, life and well-being, work, or Inability to relax 2,962 75.6 957 24.4 study. They were also asked if they had psychological help online Lossoffreedom 2,716 69.3 1,203 30.7 [0 = no; 1 = yes], and how they rated this new tool (excellent, Lack of concentration 2,476 63.2 1,443 36.8 odd but it works, it generates disgust, or no good). Irritability 2,370 60.5 1,549 39.5 Another aspect related to psychological support was to ask Restlessness 2,281 58.2 1,638 41.8 about the future need for psychological help after lockdown [0 Future concern = no; 1 = yes]. For this question, all survey respondents had Employment 1,837 46.9 2,082 53.1 to answer. School 3,365 85.9 554 14.1 Financial issues 1,966 50.2 1,953 49.8 Data Analysis Policy 2,437 62.2 1,482 37.8 Given the exploratory nature of the study, the data analysis Mental health 2,654 67.7 1,265 32.3 had two pivotal moments. The first moment consisted of the Stigma 3,860 98.5 59 1.5 estimation of descriptive statistics for each of the variables of Overall health 1,751 44.7 2,168 55.3 interest. Most of the study variables were measured as categorical variables, so their frequencies and total percentages were studied. In a second moment, bivariate relations between the variables Similarly, 49.8% of participants reported being concerned about of interest were calculated. When two categorical variables economic issues. In contrast, only 1.5% of participants reported were associated, a chi-squared statistic was used to determine being concerned about stigma. a statistically significant relationship, and when a categorical variable was related to a quantitative one, the Student t statistic Vulnerability Factors Related to Perceived was used to determine statistically significant differences. All Psychological Impact and Future Concern statistical analyses were carried out using R v4.0.0 software (54). Age, Perceived Psychological Impact, and Future Concern RESULTS When looking at the perceived psychological impact in relation to age, it can be seen in Table 2 that, for all feelings, the average Perceived Psychological Impact and age for people who reported feeling them was significantly lower Future Concern (p’s < 0.01). The widest difference was observed in the feeling Table 1 shows the percentage of data of the different perceived of frustration, where those who reported this feeling were on psychological impacts reported by the study participants. It can average 35.36 years old, and those who did not report it were be seen that the most frequently reported feeling was concern, on average 43.34 years old (t = 21.28, p < 0.001). The perceived with 67% of people reporting it. Next, the second most frequently psychological impact where the least age difference could be reported perceived impact was anxiety, with 60% of the sample observed was worry, where those who reported feeling this way reporting feeling it during quarantine. On the other hand, were, on average, 42.24 years old, while those who did not report feelings of loneliness were the second least reported, namely, being worried were 43.77 years old (t = 3.10, p = 0.002). 16% of the sample, and a feeling of loss of control was the Comparisons between participants’ ages who reported, and least reported perceived impact, with only 9.5% of participants did not report, different types of concern during quarantine reporting feeling it. are shown in Table 3. As a general trend, younger participants Regarding future concerns of the participants, Table 1 shows reported employment, finances, mental health, stigma, and that the most frequent concern was overall health, with 55.3% of general health concerns (p’s < 0.001). However, no significant the sample reporting it. Next, with a similar percentage, 53.1% differences could be observed in the age of participants that of participants reported feeling concerned about work issues. reported school and political concerns.

Frontiers in Psychiatry | www.frontiersin.org 4 November 2020 | Volume 11 | Article 591142 Dagnino et al. COVID-19 Psychological Effects in Chile

TABLE 2 | The average age of perceived impact reports on current feelings.

Does not report Report t

M DE M DE

Fear 43.98 14.38 40.17 13.18 8.24*** Concern 43.77 17.77 42.24 13.75 3.10** Frustration 43.34 13.72 35.36 12.50 21.28*** Boredom 40.06 13.14 36.51 13.76 21.03*** Anxiety 48.03 13.86 39.26 13.16 19.80*** Distress 45.59 14.01 38.59 13.19 15.90*** Feeling trapped 44.57 13.73 36.85 13.71 14.96*** Lossofcontrol 43.30 14.26 37.45 11.24 9.30*** Loneliness 43.88 13.58 36.88 15.26 10.76*** Sleepproblems 44.92 14.17 39.55 13.40 12.05*** Inability to relax 44.68 14.05 36.76 12.52 16.49*** Lossoffreedom 44.21 13.96 39.43 13.89 9.93*** Lack of concentration 45.76 13.83 37.57 13.04 18.52*** Irritability 45.82 14.42 38.02 12.20 18.18*** Restlessness 44.19 13.77 40.72 14.32 7.60***

***p < 0.001, **p < 0.01, *p < 0.05.

Gender, Perceived Psychological Impact, and Future 0.001). In contrast, a higher percentage of people with dependent Concern employment reported having mental health and general health Table 4 shows the percentage of men and women who reported concerns (p’s < 0.001). For school, policy, and stigma concerns, different perceived psychological impacts. In general, some no statistically significant differences were observed between the statistically significant gender differences can be highlighted. work mode of the study participants. The perception of fear, worry, frustration, anxiety, distress, feeling trapped, loss of control, sleep problems, inability to relax, Previous Psychological Support irritability, and restlessness were reported mostly by women(p’s Table 8 shows the percentage of data on the number of < 0.05). However, 40.1% of the men in the sample reported participants who had received pre-quarantine psychological feeling bored, while only 33.5% of the women reported boredom therapy and some particularities of the treatment they received. 2 = = (χ 11.82, gl 1, p < 0.001). In terms of feelings of loneliness, From all of the sample, 22.3% of participants reported loss of freedom, and lack of concentration, no gender differences that they had received some type of psychological therapy were observed. before quarantine. On gender differences in each of the future concerns studied Of the participants that reported being in treatment, 54.7% Table 5 (see ), more men reported having more future concerns reported that they had more than 6 sessions and 19.2% reported on employment and politics than women (p’s < 0.05). However, that they had more than 12 sessions. In general, the most for mental health and general health concerns, more women recurrent frequency was weekly sessions, with 51.1% of the study reported having them (p’s < 0.01). And for school, financial, participants reporting having followed this format. However, and stigma concerns, no statistically significant differences 19.2% reported receiving sessions once a month, and 17.3% had were observed. no fixed frequency of their sessions. The most recurrent reason for consultation was anxiety, Occupation, Perceived Psychological Impact, and with 47.14% of participants receiving therapy, followed by Future Concern depression, with 39.36%. Among the least frequent reasons for For reporting current perceived psychological impacts and the consultation in the sample were cognitive and learning problems type of occupation that the participants had, those working as (1.95%), psychosis (2.17%), and addictions (2.63%). Finally, employees were compared with those who were self-employed. only 7.6% of participants who had previously been receiving The results of this comparison can be seen in Table 6. In general, emotional support reported that they were currently attending there was a higher percentage of employed workers who reported psychological therapy. When asked about this experience, most feeling bored, anxious, distressed, experiencing sleep problems, of them referred to having a positive experience, or at least feeling an inability to relax, and a lack of concentration (p’s < 0.05). that it was helping them (97.3%). For the rest of the perceived psychological impacts, no significant differences were observed. Perceived Impact, Previous Psychological Support, Table 7 shows the results for the type of concern reported by and Future Needs both types of occupation. A majority of self-employed workers Table 9 shows the associations between the percentage of people reported feeling employment and financial concerns (p’s < who reported having received psychotherapy before quarantine

Frontiers in Psychiatry | www.frontiersin.org 5 November 2020 | Volume 11 | Article 591142 Dagnino et al. COVID-19 Psychological Effects in Chile

TABLE 3 | Average age of future concern reports.

Does not report Report t

M DE M DE

Employment 43.73 14.96 41.88 13.25 4.06*** School 42.70 14.76 43.05 9.20 −0.76 Financial issues 43.56 14.86 41.94 13.26 3.57*** Policy 43.04 13.46 42.26 15.11 1.63 Mental health 45.30 13.88 37.38 13.03 17.31*** Stigma 42.84 14.10 36.49 13.30 3.67*** Overall health 43.61 13.71 42.04 13.39 3.48***

***p < 0.001, **p < 0.01, *p < 0.05.

TABLE 4 | Percentage of reporting of perceived impact on current feelings by gender.

2 Male Female χ (1)

F % F %

Fear 161 20.5 1,110 35.4 63.37*** Concern 480 61.1 2,151 68.7 16.05*** Frustration 169 21.5 852 27.2 10.27** Boredom 315 40.1 1,048 33.5 11.82*** Anxiety 405 51.5 1,958 62.5 31.13*** Distress 213 27.1 1,382 44.1 74.64*** Feeling trapped 163 20.7 765 24.4 4.50* Lossofcontrol 52 6.6 321 10.2 9.20** Loneliness 115 14.6 521 16.6 1.70 Sleepproblems 239 30.4 1,351 43.1 41.60*** Inability to relax 169 21.5 788 25.2 4.39* Lossoffreedom 221 28.1 982 31.3 2.93 Lack of concentration 266 33.8 1,177 37.6 3.6 Irritability 2.36 30.0 1,313 41.9 36.6*** Restlessness 300 38.2 1,338 42.7 5.13*

***p < 0.001, **p < 0.01, *p < 0.05. Only the percentages of people who reported having the sensation are included in the table, for ease of reading.

TABLE 5 | Percentage of reporting of future concern by gender.

2 Male Female χ (1)

f % f %

Employment 448 57.0 1,634 52.2 5.72* School 101 12.8 453 14.5 1.21 Financial issues 387 49.2 1,566 50.0 0.11 Policy 337 42.9 1,988 36.5 10.43** Mental health 218 27.7 1,047 33.4 9.02** Stigma 11 1.4 48 1.4 0.01 Overall health 371 47.2 1,797 57.4 25.81***

***p < 0.001, **p < 0.01, *p < 0.05. Only the percentages of people who reported having the concern are included in the table, for ease of reading. and the feelings they were currently experiencing. In general, psychological help (p’s < 0.01). However, the association people who had received some kind of previous psychotherapy between previous psychological treatment and feeling reported feeling most of the perceived psychological impacts worried was not statistically significant (χ 2 = 1.26, gl = 1, studied in higher percentages than those who did not have p = 0.28).

Frontiers in Psychiatry | www.frontiersin.org 6 November 2020 | Volume 11 | Article 591142 Dagnino et al. COVID-19 Psychological Effects in Chile

TABLE 6 | Percentage of reporting of impact on current feelings by occupation.

2 Employed worker Self-employed worker χ (1)

f % f %

Fear 608 33.6 305 30.1 3.52 Concern 1,227 67.9 682 67.3 0.07 Frustration 410 22.7 228 22.5 0.01 Boredom 565 31.3 280 27.6 3.89* Anxiety 1,135 62.8 544 53.7 21.98*** Distress 736 40.7 341 33.7 13.44*** Feeling trapped 401 22.2 197 19.4 2.76 Lossofcontrol 179 9.9 88 8.7 0.98 Loneliness 242 13.4 118 11.6 1.62 Sleep problems 740 41.0 354 34.9 9.61** Inability to relax 460 25.5 177 17.5 23.20*** Lossoffreedom 509 28.2 298 29.5 0.43 Lack of concentration 685 37.9 308 30.4 15.69*** Irritability 708 39.2 368 36.3 2.12 Restlessness 715 39.6 416 41.1 0.54

***p < 0.001, **p < 0.01, *p < 0.05. Only the percentages of people who reported having the sensation are included in the table, for ease of reading.

TABLE 7 | Percentage of reporting of future concern by occupation.

2 Employed worker Self-employed worker χ (1)

f % F %

Work 907 50.2 632 62.4 38.45*** School 293 16.2 149 14.7 1.00 Economicissues 819 45.3 630 62.2 73.26*** Policy 664 36.7 373 36.8 0.01 Mental health 609 33.7 215 21.2 48.26*** Stigma 24 1.3 14 1.4 0.01 Overall health 1,039 57.5 487 48.1 22.83***

***p < 0.001, **p < 0.01, *p < 0.05. Only the percentages of people who reported having the concern are included in the table, for ease of reading.

Perceived Impact and the Need for Further support before quarantine, the psychological effects on them of Psychological Support interruption of the process due to quarantine, and the usefulness Finishing with the studied perceived psychological impacts, we of online psychotherapy. It was intended to explore the likely see in Table 10 the association between the current feelings and need for psychological support after lockdown. reporting the need for psychological support after quarantine. As we know, worldwide, COVID-19 has caused a parallel Of the total number of respondents, 43.8% (1,717) reported that epidemic of fear, anxiety, depression, and concern about the they thought they would need some psychological help post- future. In this study, being in quarantine for the first 2 weeks quarantine. These participants reported a statistically significant of this pandemic had adverse effects on the participants. Mainly, higher frequency of all the perceived psychological impacts the results show a high presence of general concern and anxiety, studied than those who reported they would not need help consistent with COVID-19 research [e.g., (12, 20, 55)] and (p’s < 0.001). past research on the psychological consequences of quarantine during a pandemic (14). Unlike other studies, we did not find DISCUSSION a high presence of sleep problems (26), and the results even showed a lower presence of loneliness than was evident in other The goal of the present study was to examine through a survey the studies (28). perceived psychological impact and future concerns regarding Regarding future concerns, this study shows how a higher the COVID-19 lockdown in Santiago, Chile. The study also number of participants reported being concerned about their aimed to identify those participants receiving psychological overall health, work, and economic issues. General health has

Frontiers in Psychiatry | www.frontiersin.org 7 November 2020 | Volume 11 | Article 591142 Dagnino et al. COVID-19 Psychological Effects in Chile

TABLE 8 | Frequencies and percentages for previous, current, and future such as economic or social concerns. On the other hand, South psychological support. America has been the last continent to be struck by COVID-19,

f % and therefore, the information from the mass media has been intense in terms of health issues, with an increasing number of Previous psychological support deaths worldwide. This could explain how health concerns were No 3,045 77.7 very prevalent, even though there were fewer deaths than in other Yes 874 22.3 countries. The high presence of economic and financial concerns Therapeutic process progress may be understandable because Chile has a particular condition: Few sessions 228 26.1 in October 2019, there was a social outbreak that lasted until More than 6 478 54.7 the beginning of the pandemic. During this outbreak, 600,000 More than 12 168 19.2 employees were fired, so the economy was a big concern before Frequency of psychotherapy sessions COVID-19, and the country was not prepared for this huge More than once a week 29 3.3 possible effect. Weekly 447 51.1 When considering vulnerability factors, this study showed Less than once a week 79 9.0 that one of the factors is younger people, who reported the most Once a month 168 19.2 significant perceived psychological impact, with their main issue No fixed frequency 151 17.3 being frustration. These results are consistent with the findings Reason for consultation of Qiu et al. (19) and others (17, 58) of higher emotional distress among individuals aged between 18 and 30. Young people tend Depression 344 39.36 to obtain a large amount of information from social media, Anxiety 412 47.14 which can easily trigger stress (45, 59). However, in addition, Psychosis 19 2.17 actual studies on COVID-19 have shown how people aged 60 Cognitive and learning problems 17 1.95 or above have also reported high levels of psychological distress. Personality problems 52 5.95 This study did not find this result. In fact, older people reported Eating disorders 57 6.52 a low presence of perceived psychological impact compared Physical problems 34 3.89 with other ages. This is an unusual result, since every study Addictions 23 2.63 on COVID-19 and prior pandemics (19) has shown the huge Trauma abuse 107 12.24 perceived impact on this group. A possible hypothesis is that, as Grief 122 13.96 this survey was carried out in the first 2 weeks of quarantine, Self-esteem 210 24.03 older people had already been prepared and isolating as a Interpersonal relations 263 30.09 precaution, and therefore, it did not have the same perceived Life and well-being 250 28.60 impact as a sudden quarantine, as in other groups, especially Work or study 164 18.76 the young. Current psychological support As expected, as in other studies, gender is a vulnerability No 3,620 92.4 factor, mainly for women, who reported having more perceived Yes 299 7.6 psychological impacts, while men mainly felt bored. We can Experience with current understand that women had perceived more negative impacts virtual psychological support than men, since some of the authors report that women are, Excellent 96 32.1 in fact, more vulnerable to stress than their counterparts, and Odd, but it works 195 65.2 they are therefore more susceptible to negative feelings and It generates disgust 1 0.3 even post-traumatic stress disorders (12, 19, 31). The fact that No good 7 2.3 the main negative feeling among men was being bored is challenging to understand, but it may have to do with the time of the survey, namely, the first 2 weeks of quarantine, meaning there were still no other perceived impacts on men since it been one of the main concerns during quarantine [e.g., (52)], as was in the early stages. Women may be more susceptible to the number of deaths has been increasing worldwide, and second connecting to the probable psychological and health impact. outbreaks have even appeared in countries where the pandemic These gender differences have been detected in many other was supposedly under control. studies, for example, Wang et al. (21). Furthermore, some studies have shown how economic On future concerns, gender differences were also found. Men concern is a dimension (38, 39, 56, 57). However, what this reported having more concerns about work and politics than study found to be different from the rest is how concerns about women. Meanwhile, women were concerned about their mental work and economic issues had the same relevance as overall and overall health. These differences can probably be explained health. There are many possible interpretations of this, and by traditional male and female gender roles, which are prevalent some authors [e.g., (53)] have concluded that the perceived in South American countries such as Chile. Even though Chile psychological impact of COVID-19 has an impact on health is a developing country, women tend to develop many roles, concerns, but also quarantine shows other stress-related factors, such as employees, housewives, and childcare providers, while

Frontiers in Psychiatry | www.frontiersin.org 8 November 2020 | Volume 11 | Article 591142 Dagnino et al. COVID-19 Psychological Effects in Chile

TABLE 9 | Percentage of reporting of perceived impact on actual feelings by previous psychological support.

2 No Ye χ (1)

f % F %

Fear 926 30.4 345 39.5 25.04*** Concern 2,030 66.7 601 68.8 1.26 Frustration 722 23.7 299 34.2 38.16*** Boredom 1,012 33.2 351 40.2 14.05*** Anxiety 1,736 57.0 627 71.7 60.91*** Distress 1,144 37.6 451 51.6 54.82*** Feeling trapped 657 21.6 271 31.0 32.89*** Lossofcontrol 262 8.6 111 12.7 12.76*** Loneliness 429 14.1 207 23.7 45.29*** Sleep problems 1,199 39.4 391 44.7 7.87** Inability to relax 678 22.3 279 31.9 33.76*** Lossoffreedom 893 29.3 310 35.5 11.75*** Lack of concentration 1,053 34.6 390 44.6 29.00*** Irritability 1,152 37.8 397 45.2 16.05*** Restlessness 1,237 40.6 401 45.9 7.5**

***p < 0.001, **p < 0.01, *p < 0.05. Only the percentages of people who reported having the sensation are included in the table, for ease of reading.

TABLE 10 | Percentage of reporting of perceived psychological impact on current feelings by the need for further support.

2 No Ye χ (1)

f % f %

Fear 492 22.3 779 45.4 232.42*** Concern 1,351 61.4 1,280 74.5 75.36*** Frustration 403 18.3 618 36.0 155.82*** Boredom 668 30.3 695 40.5 43.28*** Anxiety 1,037 47.1 1,326 77.2 364.68*** Distress 611 27.7 984 57.3 348.10*** Feeling trapped 389 17.7 539 31.4 99.81*** Lossofcontrol 122 5.5 251 14.6 91.27*** Loneliness 217 9.9 419 24.4 149.13*** Sleepproblems 642 29.2 948 55.2 270.60*** Inability to relax 329 14.9 628 36.6 243.49*** Lossoffreedom 560 25.4 643 37.4 65.93*** Lack of concentration 600 27.2 843 49.1 197.04*** Irritability 681 30.9 868 50.6 154.66*** Restlessness 754 34.2 884 51.5 117.21***

***p < 0.001, **p < 0.01, *p < 0.05. Only the percentages of people who reported having the sensation are included in the table, for ease of reading. men are usually focused on work and concerned about financially the global prevalence of both disorders worldwide and in supporting the family (60). Chile (61, 62). The other group evaluated had not been considered in When assessing the perceived psychological impacts that these any other studies, or in studies on COVID-19 or other participants reported, it was found that they had more, and a pandemics. Of those people who were receiving psychological broader, perceived psychological impact than participants who support before quarantine, 22% of the participants had this were not receiving this support before lockdown. These results support before lockdown. Almost half of them had more confirm that the psychological impact of quarantine could more than six sessions on a weekly basis. Their initial consultations substantially influence people with mental health issues, and, were mainly on anxiety and depression, which coincides with therefore, it may worsen their symptoms because of their high

Frontiers in Psychiatry | www.frontiersin.org 9 November 2020 | Volume 11 | Article 591142 Dagnino et al. COVID-19 Psychological Effects in Chile susceptibility to stress compared with the general population generalized to all of the population, but hopefully, they will (48, 63, 64). motivate further studies that cover the Chilean population Quarantine disrupts people’s lives, especially since there is more generally. no possibility of getting around or carrying out daily activities Regarding the survey’s validity, our instrument was not a outside the home (11, 12). Therefore, one of the most interrupted standardized scale designed to measure psychological disorders. activities was the possibility of attending psychological support So, the results on psychological symptoms during the pandemic sessions. For this reason, services are developing expertise in are proxies that give us hints about the psychological well-being conducting psychiatric assessments and delivering interventions of the Chilean population. This is especially important because, remotely (e.g., by telephone or digitally). There has been without a standard survey, some issues with comparability rise. worldwide discussion about the change of setting this entails and Furthermore, given the metric and heterogeneous nature of how therapists are coping with it, but the viewpoint of patients our items, reliability measures such as Cronbach’s alpha could has gone unnoticed. In this study, most of the participants not be estimated. However, the present research was aimed at who had virtual support evaluated it as excellent or rare but screening as many symptoms as possible to offer a descriptive useful. This is very important because it confirms that these basis for future studies, so we decided to use single items for new working practices should be implemented more widely. The each symptom based on previous research [e.g., (8, 20, 52, 68)]. results showed that almost half of respondents (43.8%) reported Furthermore, our results are in line with reports from the current that they believed they needed future psychological support, literature. Nevertheless, it is recommended that future studies which confirms and emphasizes the importance of having devices use standardized instruments to confirm our findings. Another that allow psychological support on a broader scale, benefiting a issue is the limitations self-report assessment has, compared more significant part of the population. This is highly relevant with face-to-face interviews, since the latter may give more and because the expectation is that, even as contagion decreases reliable information. worldwide, many people will still be on voluntary quarantine. As the pandemic has developed, new research has appeared, This study emphasizes the high presence of psychological showing new variables that must be taken into account for effects due to initial quarantine on COVID-19, showing mainly future studies that were not considered for this research. anxiety and concern. As Forte et al. (65) state, this pandemic Relevant to this topic is specific symptomatology, since new could even be considered a traumatic event. Vulnerability groups studies have found a high prevalence of stress, post-traumatic were identified through this study, including women, younger disorder, depression, general anxiety, and a deterioration of people, and the self-employed, who had a higher presence of sleep quality (25, 26, 53, 65). On the other hand, past adverse perceived psychological effects. Because of its magnitude, this experiences must be taken into account since they highly relate study confirms the need for a national strategic and coordination to symptomatology. This information is relevant because it plan for psychological support, aimed at vulnerable groups, may increase psychological vulnerability to COVID (69). Other which goes beyond healthcare workers, survivors, or parents in dimensions must be considered, such as having contact with charge of small children. a family member or friend with COVID-19. Favieri et al. (53) However, the general population is suffering from negative found a low level of psychological well-being among those with psychological impacts, such as women, younger people, the self- such contact. employed, and those with interrupted psychological help. The Moreover, there are groups of people with other vulnerabilities delivery of this support must be virtual because of its high that were not taken into account, such as those suffering potentiality (66, 67), and mainly because this study showed from chronic medical conditions, who are more vulnerable that it is perceived to be effective for patients. Some authors to severe disease outcomes (25, 26); health workers on the (33, 46) have been developing a specialized psychological frontline of COVID-19, who have a higher possibility of being intervention for COVID-19 that must be dynamic and flexible infected; people talking care of children (20); family; and enough to adapt quickly to the different phases of the specially survivors (25, 67). In fact, patients who recovered from pandemic and the specific groups. Finally, Van Daele et al. COVID-19 suffer afterwards from multiple sequelae on several (50) have made some specific recommendations for policy- organs and psychiatric symptoms that require a multidisciplinary makers on e-mental health and tele-psychotherapy, which must approach (70). be considered. Finally, many researchers have pointed out [e.g., (52)] that it is essential to understand the potential psychological changes Limitations and Further Research caused by COVID-19 over time. As the pandemic continues, Because this was an exploratory study, carried out during it is expected that the negative impact will have more severe the first 2 weeks of quarantine in Santiago, it has several consequences with long-lasting effects (26). One of the study’s limitations. The first relates to the sample, since it is not a limitations is that the survey was carried out at one time point. probabilistic sample of the Chilean population. Furthermore, However, Qiu et al. (19) found a decrease in distress levels as time the sample is biased because it was obtained through personal passes. However, a recent study undertaken in the USA, using contacts and social networks on which we did not explore the a longitudinal data set, showed stable levels of stress, anxiety, participation rate. The sample implied a few sample biases, for and depression between two surveys and, therefore, no clinically example, gender (more women) and level of studies (mostly significant reduction in the perceived psychological impact on the university or postgraduate). Therefore, the results cannot be general population (71).

Frontiers in Psychiatry | www.frontiersin.org 10 November 2020 | Volume 11 | Article 591142 Dagnino et al. COVID-19 Psychological Effects in Chile

Qiu et al. (19) attributed the decrease of distress to the Diego Portales (N◦006-2020). The patients/participants provided effective prevention and control measures taken by the Chinese their written informed consent to participate in this study. government, which has shown itself to be effective and exerting more control through rapidly closing its borders, increasing AUTHOR CONTRIBUTIONS traceability, and adequate data information. Chile, on the other hand, started the pandemic with contradictory information and PD and VA: conceptualization, methodology, formal analysis, with restrictive measures suddenly adopted. All of this could and writing—original draft. KE and SC: writing—reviewing draft have provoked an intense perceived psychological impact at the and editing. All authors: contributed to the article and approved beginning, because of the uncertainty, and as time passes, it may the submitted version. become even more intense with the increase in deaths and the possibility of a second wave. Either way, a follow-up must be undertaken to identify these FUNDING patterns and participants’ characteristics to develop a target We would like to express our gratitude for the support and intervention if necessary, for each of the phases of the pandemics. funding of ANID/CONICYT, FONDECYT Iniciación 11170561, ANID Millennium Science Initiative/Millennium Institute for DATA AVAILABILITY STATEMENT Research on Depression and Personality—MIDAP ICS13_005, the Center of Psychotherapy Research, Cipsi, and Universidad The datasets generated for this study are available upon request Alberto Hurtado. to the corresponding author.

ETHICS STATEMENT ACKNOWLEDGMENTS

The studies involving human participants were reviewed and We would like to thank every participant that took the time to approved by the Institutional Review Board of the Universidad answer our survey.

REFERENCES 13. Bai Y, Lin CC, Lin CY, Chen JY, Chue CM, Chou P. Survey of stress reactions among health care workers involved with the SARS outbreak. Psychiatr Serv. 1. Worldometer. Available online at: https://www.worldometers.info/ (2004) 55:1055–7. doi: 10.1176/appi.ps.55.9.1055 coronavirus/#countries (accessed July 28, 2020). 14. Wu P, Fang Y, Guan Z, Fan B, Kong J, Yao Z, et al. The psychological 2. Tikitakas. Available online at: https://chile.as.com/chile/2020/04/15/tikitakas/ impact of the SARS epidemic on hospital employees in China: exposure, 1586952484_139894.html (accessed April 15, 2020). risk perception, altruistic acceptance of risk. Can J Psychiatry. (2009) 54:302– 3. Sociedad Chilena de Medicina Intensiva. Available online at: 11. doi: 10.1177/070674370905400504 www.medicina-intensiva.cl/site/post_covid.php?id=201 (accessed September 15. Newman K. Shut up: bubonic plague and quarantine in early modern England. 10, 2020). J Sol Hist. (2012) 45:809–34. doi: 10.1093/jsh/shr114 4. Wang C, Horby PW, Hayden FG, Gao GF. A novel coronavirus 16. Cowan K. Survey Results: Understanding People’s Concerns About the Mental outbreak of global health concern. Lancet. (2020) 395:470– Health Impacts of the COVID-19 Pandemic. London: Academy of Medical 3. doi: 10.1016/S0140-6736(20)30185-9 Sciences (2020). Available online at: https://acmedsci.ac.uk/file-download/ 5. Cao Z, Zhang Q, Lu X, Pfeiffer D, Jia Z, Song H, et al. Estimating the effective 99436893 reproduction number of the 2019-nCoV in China. medRxiv [Preprint]. (2020). 17. Huang Y, Zhao N. Generalized anxiety disorder, depressive symptoms and doi: 10.1101/2020.01.27.20018952 sleep quality during COVID-19 epidemic in China: a web-based cross- 6. Centers for Disease Control and Prevention. How Coronavirus Spreads. sectional survey. medRxiv [Preprint]. (2020). doi: 10.21203/rs.3.rs-17172/v1 Available online at: https://www.cdc.gov/coronavirus/2019-ncov/prepare/ 18. Sønderskov KM, Dinesen PT, Santini ZI, Ostergaard SD. The depressive state transmission.html (accessed April 15, 2020). of Denmark during the COVID-19 pandemic. Acta Neuropsychiatr. (2020) 7. Damir H. Psychiatry of Pandemics: A Mental Health Response to Infection 22:1–3. doi: 10.1017/neu.2020.15 Outbreak. Bern: Springer (2019). 19. Qiu J, Shen B, Zhao M, Wang Z, Xie B, Xu Y. A nationwide 8. Taylor S. The Psychology of Pandemics: Preparing for the Next Global Outbreak survey of psychological distress among Chinese people in the COVID-19 of Infectious Disease 2019. Newcastle: Cambridge Scholars Publishing (2019). epidemic: implications and policy recommendations. Gen Psychiatry. (2020) p. 155. 33:e100213. doi: 10.1136/gpsych-2020-100213 9. Organización Mundial de la Salud. Available online at: http://who.int 20. Stankovska G, Memedi I, Dimitrovski D. Coronavirus COVID-19 disease, (accessed September 10, 2020). mental health and psychosocial support. Social Regist. (2020) 4:33– 10. Malathesh BC, Chatterjee SS, Das S. Overview of mental health 48. doi: 10.14746/sr.2020.4.2.03 issues of COVID-19: need of the hour. Gen Psychiatry. (2020) 21. Wang C, Pan R, Wan X, Tan Y, Xu L, McIntyre RS, et al. A longitudinal study 33:e100233. doi: 10.1136/gpsych-2020-100233 on the mental health of general population during the COVID-19 epidemic in 11. Giallonardo V, Sampogna G, Del Vecchio V, Luciano M, Albert U, Carmassi China. Brain Behav Immun. (2020) 87:40–8. doi: 10.1016/j.bbi.2020.04.028 C, et al. The impact of quarantine and physical distancing following COVID- 22. Zhang SX, Wang Y, Rauch A, Wei F. Unprecedented disruption of 19 on mental health: study protocol of a multicentric Italian population trial. lives and work: health, distress and life satisfaction of working adults in Front Psychiatry. (2020) 11:533. doi: 10.3389/fpsyt.2020.00533 China one month into the COVID-19 outbreak. Psychiatry Res. (2016) 12. Lima CKT, Carvalho PMM, Lima IAAS, Nunes JVAO, Saraiva JS, de Souza 288:112958. doi: 10.1016/j.psychres.2020.112958 RI, et al. The emotional impact of coronavirus 2019-Ncov (new coronavirus 23. Wan W. The coronavirus pandemic is pushing America into a mental health disease). Psychiat Res. (2020) 287:112915. doi: 10.1016/j.psychres.2020. crisis (2020). Available online at: https://www.washingtonpost.com/health/ 112915 2020/05/04/mental-health-coronavirus/ (accessed April 23, 2020).

Frontiers in Psychiatry | www.frontiersin.org 11 November 2020 | Volume 11 | Article 591142 Dagnino et al. COVID-19 Psychological Effects in Chile

24. Gritsenko V, Skugarevsky O, Konstantinov V, Khamenka N, Marinova T, 43. Barbisch D, Koenig KL, Shih FY. Is there a case for quarantine? Reznik A, et al. COVID-19 19 fear, stress, anxiety, and substance use among Perspectives from to Ebola. Disaster Med Public Health Prep. (2015) 9:547– Russian and Belarusian university students. Int J Ment Health Addict. (2020) 53. doi: 10.1017/dmp.2015.38 21:1–7. doi: 10.1007/s11469-020-00330-z 44. Yao H, Chen JH, Xu Y. Patients with mental health 25. Mazza C, Ricci E, Biondi S, Colasanti M, Ferracuti S, Napoli C, disorders in the COVID-19 epidemic. Lancet Psychiatry. (2020) et al. A nationwide survey of psychological distress among Italian 7:e21. doi: 10.1016/S2215-0366(20)30090-0 people during the COVID-19 pandemic: immediate psychological 45. Cheng C, Jun H, Liang B. Psychological health diathesis assessment system: responses and associated factors. Int J Environ Res Public Health. (2020) a nationwide survey of resilient trait scale for Chinese adults. Stud Psychol 17:3165. doi: 10.3390/ijerph17093165 Behav. (2014) 12:735–42. 26. Casagrande M, Favieri F, Tambelli R, Forte G. The enemy who sealed the 46. Horesh D, Brown AD. Traumatic stress in the age of COVID-19: a call world: effects quarantine due to the COVID-19 on sleep quality, anxiety, to close critical gaps and adapt to new realities. Psychol Trauma. (2020) and psychological distress in the Italian population. Sleep Med. (2020) 75:12– 12:331–5. doi: 10.1037/tra0000592 20. doi: 10.1016/j.sleep.2020.05.011 47. Jeong H, Yim HW, Song Y, Ki M, Min JA, Cho J, et al. Mental health status 27. Pakpour AH, Griffiths MD. The fear of COVID-19 and its role in preventive of people isolated due to middle east respiratory syndrome. Epidemiol Health. behaviors. J Concurrent Disord. (2020) 2:58–63. (2016) 38:e2016048. doi: 10.4178/epih.e2016048 28. Tull MT, Edmonds KA, Scamaldo KM, Richmond JR, Rose JP, Gratz 48. Pereira-Sanchez V, Adiukwu F, El Hayek S, Bytyçi DG, Gonzalez- KL. Psychological outcomes associated with stay at home orders and Diaz JM, Kundadak GK, et al. COVID-19 effect on mental the perceived impact of COVID-19 on daily life. Psychiatry Res. (2020) health: patients and workforce. Lancet Psychiatry. (2020) 7:e29– 289:113098. doi: 10.1016/j.psychres.2020.113098 30. doi: 10.1016/S2215-0366(20)30153-X 29. Sorokin MY, Kasyanov ED, Rukavishnikov GV, Makarevich OV, Neznanov 49. Pfefferbaum B, North C. Mental health and the COVID-19 pandemic. N Engl NG, Lutova NB, et al. Structure of anxiety associated with the COVID- J Med. (2020) 383:510–12. doi: 10.1056/NEJMp2008017 19 pandemic in the Russian-speaking sample: results from online survey. 50. Van Daele T, Karekla M, Kassianos AP, Compare A, Haddouk L, Salgado J, medRxiv [Preprint]. (2020). doi: 10.24075/brsmu.2020.030 et al. Recommendations for policy and practice of tele-psychotherapy and 30. Lai J, Ma S, Wang Y, Cai Z, Hu J, Wei N, et al. Factors e-mental health in Europe and beyond. J Psychother Integr. (2020) 30:160– associated with mental health outcomes among health care workers 73. doi: 10.1037/int0000218 exposed to coronavirus disease 2019. JAMA Netw Open. (2019) 51. Liu S, Yang L, Zhang C, Xiang YT, Liu S, Hu S, et al. Online mental health 3:e203976. doi: 10.1001/jamanetworkopen.2020.3976 services in China during the COVID-19 outbreak. Lancet Psychiatr. (2020) 31. Sandín B, Valiente RM, García-escalera J, Chorot P. Impacto psicológico de la 7:e17–8. doi: 10.1016/S2215-0366(20)30077-8 pandemia de COVID-19 : efectos negativos y positivos en población española 52. Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N, et al. asociados al periodo de confinamiento nacional. Revis Psicopatol Psicol Clín. The psychological impact of quarantine and how to reduce it: rapid review of (2020) 25:1–22. doi: 10.5944/rppc.27569 the evidence. Lancet. (2020) 395:912–20. doi: 10.1016/S0140-6736(20)30460-8 32. Kang L, Ma S, Chen M, Yang J, Wang Y, Li R, et al. Impact on mental health 53. Favieri F, Forte G, Tambelli R, Casagrande M. The Italians in the Time and perception of psychological care among medical and nursing staff in of Coronavirus: Psychosocial Aspects of Unexpected COVID-19 Pandemic. Wuhan during the 2019 novel coronavirus disease outbreak: a cross-sectional Available online at: https://ssrn.com/abstract=3576804 study. Brain Behav Immun. (2019) 87:11–7. doi: 10.1016/j.bbi.2020.03.028 54. Xiang YT, Yang Y, Li W, Zhang L, Zhang Q, Cheung T, et al. Timely mental 33. Duan L, Zhu G. Psychological interventions for people affected health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet by the COVID-19 epidemic. Lancet Psychiatry. (2020) 7:300– Psychiatry. (2020) 7:228–9. doi: 10.1016/S2215-0366(20)30046-8 2. doi: 10.1016/S2215-0366(20)30073-0 55. Baker SR, Farrokhnia A, Meyer S, Pagel M, Yannelis C. How Does Household 34. Romero C-S, Catalá J, Delgado C, Ferrer C, Errando C, Iftimi A, et al. COVID- Spending Respond to an Epidemic? Consumption During the 2020 COVID-19 19 psychological impact in 3109 healthcare workers in Spain: the PSIMCOV Pandemic. National Bureau of Economic Research (2020). Available online at: group. Psychol Med. (2020) 14:1–7. doi: 10.1017/S0033291720001671 https://ideas.repec.org/p/nbr/nberwo/26949.html (accessed April 15, 2020). 35. Tang B, Bragazzi NL, Li Q, Tang S, Xiao Y, Wu J. An updated estimation of the 56. R Core Team. A Language and Environment for Statistical Computing. Vienna: risk of transmission of the novel coronavirus (2019-nCov). Infect Dis Model. R Foundation for Statistical Computing (2020). Available online at: http:// (2020) 5:248–55. doi: 10.1016/j.idm.2020.02.001 www.R-project.org/ (accessed April 27, 2020). 36. Huang Y, Zhao N. Generalized anxiety disorder, depressive 57. Pellecchia U, Crestani R, Decroo T, Van den Bergh R, Al-Kourdi Y. Social symptoms and sleep quality during COVID-19 outbreak in consequences of Ebola containment measures in Liberia. PLoS ONE. (2015) China: a web-based cross-sectional survey. Psychiatry Res. (2020) 10:e0143036. doi: 10.1371/journal.pone.0143036 288:112954. doi: 10.1016/j.psychres.2020.112954 58. Wang C, Pan R, Wan X, Tan Y, Xu L, Ho CS, et al. Immediate 37. Mowbray H. In Beijing, coronavirus 2019-nCoV has created a siege mentality. psychological responses and associated factors during the initial stage BMJ. (2020) 368:m516. doi: 10.1136/bmj.m516 of the 2019 coronavirus disease (COVID-19) epidemic among the 38. Roberts T, Esponda GM, Krupchanka D, Shidhaya R, Patel V, Rathod general population in China. Int J Environ Res Public Health. (2020) S. Factors associated with health service utilization for common 17:1729. doi: 10.3390/ijerph17051729 mental disorders: a systematic review. BMC Psychiatry. (2018) 59. Rajkumar RP. COVID-19 and mental health: a review of the existing 18:262. doi: 10.1186/s12888-018-1837-1 literature. Asian J Psychiatry. (2020) 52:102066. doi: 10.1016/j.ajp.2020.102066 39. DiGiovanni C, Bowen N, Ginsberg M, Giles G. Quarantine stressing voluntary 60. Blofield M, Martinez J. Trabajo, familia y cambios en la política pública en compliance. Emerg Infect Dis. (2005) 11:1778–9. doi: 10.3201/eid1111. América latina: equidad, maternalismo y corresponsabilidad. Revis CEPAL 050661 Santiago. (2014) 114:107–25. doi: 10.18356/d81c1957-es 40. Blofield M, Hoffmann B, Llanos M. Assessing the political and social impact 61. Li SW, Wang Y, Yang YY, Lei XM, Yang YF. Analysis of influencing factors of the COVID-19 crisis in Latin America. In: GIGA Focus, Vol. 3. Hamburg: of anxiety and emotional disorders in children and adolescents during home German Institute of Global and Area Studies (2020). p. 1–12. isolation during the epidemic of novel coronavirus pneumonia. Chinese J 41. Atkeson A. What Will Be the Economic Impact of COVID-19 in the Child Health. (2020) 1:1-9. US? Rough Estimates of Disease Scenarios. No. w26867. Washington, 62. Valdés C, Errázuriz P. Claves de Políticas Públicas Salud Mental en Chile: El DC: National Bureau of Economic Research (2020). doi: 10.3386/ Pariente Pobre del Sistema de Salud. Inst Polít Públicas Univ Diego Portales. w26867 (2012). Available online at: www.udp.cl (accessed October 15, 2012). 42. DiGiovanni C, Conley J, Chiu D, Zaborski J. Factors influencing 63. WHO. Depression and Other Common Mental Disorders: Global Health compliance with quarantine in Toronto during the 2003 SARS Estimates. Geneva: World Health Organization (2017). outbreak. Biosecur Bioterrorism. (2005) 2:265–72. doi: 10.1089/bsp.2004. 64. Liu X, Kakade M, Fuller CJ, Fan B, Fang Y, Kong J, et al. Depression 2.265 after exposure to stressful events: lessons learned from the severe

Frontiers in Psychiatry | www.frontiersin.org 12 November 2020 | Volume 11 | Article 591142 Dagnino et al. COVID-19 Psychological Effects in Chile

acute respiratory syndrome epidemic. Compr Psychiatry. (2012) 53:15– 70. Landi F, Gremese E, Bernabei R, Fantoni M, Gasbarrini A, 23. doi: 10.1016/j.comppsych.2011.02.003 Settanni C, et al. Post-COVID-19 global health strategies: the 65. Forte G, Favieri F, Tambelli R, Casagrande M. COVID-19 pandemic in the need for an interdisciplinary approach. Aging Clin Exp Res. (2020) Italian population: validation of a post-traumatic stress disorder questionnaire 32:1613–20. doi: 10.1007/s40520-020-01616-x and prevalence of PTSD symptomatology. Int J Environ Res Public Health. 71. Rauch SAM, Simon NM, Rothbaum BO. Rising tide: responding to the (2020) 17:4151. doi: 10.3390/ijerph17114151 mental health impact of the COVID-19 pandemic. Depress Anxiety. (2020) 66. Mak IW, Chu CM, Pan PC, Yiu MG, Chan VL. Long-term psychiatric 37:505–9. doi: 10.1002/da.23058 morbidities among SARS survivors. Gen Hosp Psychiatry. (2009) 31:318– 26. doi: 10.1016/j.genhosppsych.2009.03.001 Conflict of Interest: The authors declare that the research was conducted in the 67. Crowe M, Inder M, Farmar R, Carlyle D. Delivering psychotherapy by video absence of any commercial or financial relationships that could be construed as a 1363 conference in the time of COVID-19: some considerations. J Psychiatric potential conflict of interest. Ment Health Nurs. (2020). doi: 10.1111/jpm.12659. [Epub ahead of print]. 68. Cao W, Fang Z, Hou G, Han M, Xu X, Dong J, et al. The psychological Copyright © 2020 Dagnino, Anguita, Escobar and Cifuentes. This is an open-access impact of the COVID-19 epidemic on college students in China. Psychiatry article distributed under the terms of the Creative Commons Attribution License (CC Res. (2020) 287:112934. doi: 10.1016/j.psychres.2020.112934 BY). The use, distribution or reproduction in other forums is permitted, provided 69. Janiri D, De Rossi P, Kotzalidis GD, Girardi P, Koukopoulos AE, Reginaldi the original author(s) and the copyright owner(s) are credited and that the original D, et al. Psychopathological characteristics and adverse childhood events publication in this journal is cited, in accordance with accepted academic practice. are differentially associated with suicidal ideation and suicidal acts in mood No use, distribution or reproduction is permitted which does not comply with these disorders. Eur Psychiatry. 53:31–6. doi: 10.1016/j.eurpsy.2018.05.009 terms.

Frontiers in Psychiatry | www.frontiersin.org 13 November 2020 | Volume 11 | Article 591142